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Originally added on 20th November 2016
Last updated on 2nd December 2016

I'm running a workshop today on "Biological treatments for psychological disorders: an overview & update for therapists". You can download the 100 plus slides by clicking here. The overall outline of the day is illustrated in this slide:

Moradveisi & colleagues' 2015 paper "The influence of patients' attributions of the immediate effects of treatment of depression on long-term effectiveness of behavioural activation and antidepressant medication" is worth bearing in mind when considering combining medication and psychotherapy. The abstract of their paper reads "Patients' attributions of effects of treatment are important, as these can affect long-term outcome. Most studies so far focused on the influence of attributions to medication for anxiety and depression disorders. We investigated the effects of patients' attributions made after acute treatment on the long-term outcome of antidepressant medication (ADM) and psychological treatment (behavioural activation, BA) ... Belief in coping efficacy was the only attribution factor significantly predicting 1-year HRSD scores, controlling for condition, post-test HRSD and their interaction. It also mediated the condition differences at follow-up. Credit to self was the single attribution factor that predicted BDI follow-up scores, controlling for condition, posttest BDI, and their interaction. It partially mediated the condition differences on the BDI at follow-up. Attribution to increased coping capacities and giving credit to self appear essential. In the long-term (at 1 year follow-up), the difference in outcome between BA and ADM (with BA being superior to ADM) is at least partially mediated by attributions."

So it looks as though a cost of adding medication to psychotherapy is that the client may then put their improvement down to the medication rather than to any changes they themselves were able to make, or lessons they were able to learn. This "it was the medication that got me better" belief is likely to increase the risk of relapse in the future, possibly due to leaving the client feeling relatively powerless. If it's possible for the therapist to honestly show that any improvement made was due, at least in part, to factors other than the medication, then this is likely to be well worth doing. Again this is a potential benefit of charting client improvement across time - with significant events like starting/stopping medication noted - so that one can have a clearer idea of what benefits medication might or might not have provided - see, for example, the "Progress charts" downloadable from the "Introduction & monitoring" section in "Good knowledge".

Kemp et al's 2014 paper - "Effects of a chemical imbalance causal explanation on individuals' perceptions of their depressive symptoms" - also highlights a caution: "Although the chemical imbalance theory is the dominant causal explanation of depression in the United States, little is known about the effects of this explanation on depressed individuals. This experiment examined the impact of chemical imbalance test feedback on perceptions of stigma, prognosis, negative mood regulation expectancies, and treatment credibility and expectancy. Participants endorsing a past or current depressive episode received results of a bogus but credible biological test demonstrating their depressive symptoms to be caused, or not caused, by a chemical imbalance in the brain. Results showed that chemical imbalance test feedback failed to reduce self-blame, elicited worse prognostic pessimism and negative mood regulation expectancies, and led participants to view pharmacotherapy as more credible and effective than psychotherapy. The present findings add to a growing literature highlighting the unhelpful and potentially iatrogenic effects of attributing depressive symptoms to a chemical imbalance."